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OHSU Flu Vaccine Consent Form

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Influenza Vaccination Attestation or Declination

All applicants must complete either the Attestation or the Declination

Attestation of Influenza Vaccination

By my signature below, I attest that I have received the 2010 influenza vaccination from a provider other than Providence.

Vaccination Clinic Location Vaccination Date

Practitioner Signature

Signature Date

Practitioner Name (print)

Declination of Influenza Vaccination

My Medical Staff Leadership has required that I receive influenza vaccination to protect the patients I serve, my colleagues, my family and my community. I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.

• Influenza vaccination is recommended for me and all other healthcare workers to protect our patients and colleagues from influenza disease, its complications, and death.

• If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms appear. Shedding the virus can spread influenza disease to all people with whom I come in contact or those in close proximity to me.

• If I become infected with influenza, even when my symptoms are mild or non-existent, I can spread severe illness to others.

• I understand that the strains of virus that cause influenza infection change almost yearly, which is why a different influenza vaccine is recommended each year.

• I understand that I cannot get influenza from the influenza vaccine.

• The consequences of my refusal to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including my patients and other patients in this healthcare setting, my coworkers, my family and my community.

Despite the information provided I am choosing to decline influenza vaccination right now. I understand:

• I may change my mind at any time and accept influenza vaccination, if vaccine is available

• I will be required to wear a face mask at all times when on the premises of any Providence Regional Medical Center Everett facility during the time period the Snohomish County Health Officer declares that influenza is active in the community. I understand that my mask may be removed during meal and rest breaks to allow me time to eat and drink without hindrance.

• I will need to notify Medical Staff Services if I received an influenza vaccination at a different location.

Regarding my decision not to receive an influenza vaccination, I understand:

• Any medical information provided via this declination will be held in my Providence Medical Staff file and will only be shared Providence Employee Health & Wellness.

• I will not be allowed to be present on any Providence premises if I refuse to receive an influenza vaccination and refuse to wear a face mask while on the premises. This will be in effect during the time period that the Snohomish County Health Officer declares that influenza is active in the community.

Vaccine Status:

I have read, fully understand and will comply with the requirements on this declination form.

Signature

Date

Practitioner (print)

Practitioner #

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What the OHSU Flu Vaccine Consent Form Is and Why It Matters

The OHSU Flu Vaccine Consent Form documents an individual’s informed authorization to receive seasonal influenza immunization at Oregon Health & Science University clinical sites. The form captures patient identifiers, relevant medical history, known allergies, pregnancy status, vaccine product and lot number, site of administration, and attestations about prior reactions. It creates a clinical record for treatment, billing, and public health reporting. In many contexts the form may be completed electronically; ESIGN and state e-signature laws permit e-signatures when identity, intent, consent, and record retention requirements are satisfied.

Why a Properly Completed Consent Form Protects Patients and Providers

A complete consent form documents informed decision-making, ensures necessary medical screening, aligns care with privacy rules, and supports billing and public health reporting.

Why a Properly Completed Consent Form Protects Patients and Providers

Who Typically Completes or Signs This Form

The form is completed and signed as part of routine immunization workflows by clinic staff, patients, and when required, parents or legal guardians.

  • Patient or competent adult — Signs to authorize vaccine and confirms medical history and allergies.
  • Parent or legal guardian — Signs when patient is a minor or lacks legal capacity; must include relationship.
  • Clinical staff or vaccinator — Verifies identity, documents vaccine details, and records administration information.

Proper role identification prevents delays and ensures consent is legally valid for clinical care and recordkeeping.

Authorized Signers and Typical Signatory Roles

Patient — Adult

An adult patient with decision-making capacity signs to indicate informed consent and acceptance of disclosed risks. The signer should match government ID or medical record name to avoid identity disputes; mismatched names can impede billing or record linkage.

Parent / Guardian

A parent or legally appointed guardian may sign for minors or incapacitated adults. The form should record the signer’s legal relationship, contact information, and, where state law requires, evidence of guardianship or parental authority.

Essential Data Fields Included on the Form

Patient Full Name: Exact legal name
Date of Birth: MM/DD/YYYY
Medical Record Number: OHSU MRN or clinic ID
Vaccine Product: Manufacturer and formulation
Lot / Expiration: Lot number and expiry
Signature Block: Signer name, role, date

Key Risks When the Form Is Incorrect or Missing

HIPAA Penalty: Civil fines; 45 CFR §164.530
Consent Invalidity: Potential clinical liability
Billing Denial: Claim rejection risk
Public Health Gaps: Incomplete registry reporting
Adverse Event Documentation: Impaired pharmacovigilance
Legal Challenge: Disputed authority to sign

Common Preparation and Completion Mistakes

  • Missing or illegible signature: unsigned forms or illegible names cause billing and consent disputes and may require reconsent.
  • Incorrect or absent lot number: without lot tracking, vaccine batch problems cannot be traced for adverse event reporting.
  • Incomplete medical history: failing to record allergies, current illness, or pregnancy status increases clinical risk.
  • Wrong signer for minors: accepting an unauthorized signer can render consent legally insufficient and delay care.

Step-by-Step: How to Complete the OHSU Flu Vaccine Consent Form

Follow these sequential steps to collect valid consent and document vaccine administration accurately.

  • 01
    1. Verify ID: Confirm patient identity using photo ID or medical record.
  • 02
    2. Review History: Check allergies, prior reactions, and current health status.
  • 03
    3. Obtain Consent: Have patient or guardian read and sign consent language.
  • 04
    4. Document Administration: Record product, lot, site, administrator, and time.

Where Completed Forms Are Stored and Who Receives Copies

Completed consent forms must be stored in the patient medical record and shared according to clinic policy and public health reporting obligations.

  • Electronic Medical Record: Primary storage for clinical access
  • State Immunization Registry: Report per state reporting rules
  • Patient Copy: Provide printed or electronic receipt
  • Billing Records: Attach consent to claims where required

How to Configure an Online Consent Workflow

Design an e-consent flow that enforces identity checks, collects required fields, and archives records securely.

Field Configuration
Authentication Method Email link, SMS code, or stronger as required
Conditional Logic Show pregnancy/allergy fields only when applicable
Accepted Attachments Photo ID or guardian documents
Storage Destination EMR export and audit trail retention

Technical and Integration Considerations for eSubmission

Choose a platform that securely stores PHI, supports audit trails, and integrates with clinical systems.

  • Formats Supported: PDF, DOCX, HTML
  • Integrations: EHRs, Google Workspace, NetSuite
  • Security Standards: TLS in transit; AES-256 at rest

Practical Tips for Accurate, Efficient Consent Collection

Use consistent processes and technology to reduce errors and ensure compliance.

Standardize the form across sites
Use a single validated consent template across clinical locations to reduce variation. Standardization simplifies staff training, reduces documentation errors, and ensures consistent data capture for immunization registries and billing systems.
Verify identity before signing
Require a photo ID or confirm MRN to match records. Strong identity checks reduce mismatched records and support legal enforceability when using electronic signatures under ESIGN and state law.
Capture vaccine lot and site details
Record manufacturer, lot number, expiry, and injection site at administration time. Accurate lot records enable tracing for safety notifications and adverse event reporting.
Provide a signed copy to the patient
Give patients an electronic or printed copy of the signed consent for their records. This improves transparency, assists continuity of care, and supports public health inquiries.

Timing and Reporting Expectations

Timing relates to seasonal immunization readiness, immediate documentation, and state reporting obligations.

Seasonal Timing:

Administer before or early in local flu season; vaccine availability typically increases in early fall.

Immediate Documentation:

Document administration at the time of vaccination to ensure clinical accuracy.

State Registry Reporting:

Report to state immunization information system per local rules and timeframes.

Consent Validity:

Consent typically applies to the single administration identified on the form unless it states otherwise.

Record Retention Reminder:

Follow HIPAA and local retention requirements for signed records.

Core Components Every Professional Consent Form Should Include

A complete form balances clear clinical information, legal consent language, and recordkeeping fields.

Informed Consent

Clear, plain-language description of purpose, benefits, and potential common side effects so the patient can make an informed choice.

Screening Questions

Pre-vaccination checklist for allergies, immunocompromising conditions, current illness, and prior vaccine reactions to identify contraindications.

Product Details

Fields for vaccine name, manufacturer, lot number, expiration date, and batch tracking to support pharmacovigilance and recalls.

Administration Log

Date, time, injection site, and vaccinator name or credentials to document clinical delivery and chain of custody.

Privacy Notice

Statement explaining how health information will be used, shared, and retained under HIPAA privacy rules.

Signature Section

Space for patient or guardian signature, printed name, relationship (if applicable), and date; include witness or verifier fields when required.

Real-World Examples of Electronic Consent in Healthcare

Healthcare organizations use e-consent to streamline immunization and other patient authorizations while maintaining compliance.

Fertility Centers of Illinois

Fertility Centers replaced paper authorizations with e-consent to centralize records and improve turnaround time

  • The airSlate SignNow team has been exceptional and responsive
  • The result improved administrative workflows while maintaining compliance and secure PHI handling.

Xerox (NetSuite Integration)

Xerox used integrated e-signature workflows to attach signed documents directly to enterprise records

  • Integration with core systems reduced manual filing steps
  • This approach supports consistent recordkeeping and audit readiness across distributed clinics.

Comparing eSignature Options for Managing Consent Forms

Vendor pricing and key capabilities vary; this table summarizes core plan and compliance distinctions to consider when choosing an eSignature provider.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Yes Yes Yes Yes
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently Asked Questions About the OHSU Flu Vaccine Consent Form

Answers to common questions about signing, corrections, minors, and legal validity for e-signed consent.


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